HEALTH HISTORY FORM

Parent/Guardian: Please complete both sides of this form and return by April 10th, 2015. If your child requires special treatments or non-oral medication (e.g. injections), contact Carmen Chan by phone at least one week before the program at (415) 561-7766.

Child’s Name______

Date of Birth ______Age______Weight ______

Parent/ Guardian Name______

Parent/Guardian Emergency Contact #______

Physician or Health Care Facility: Name ______Phone______

Parent/Guardian’s Health Insurance: Company______Policy No______

NOTES TO PARENTS/GUARDIANS

  1. If your child has had or has been exposed to a contagious disease or gets a serious cut, bruise, sprain, break, or other injury or skin rash during the week prior to coming to camp, please contact the Camp Manager by phone.
  1. All medications, including Bee Sting Kits/Epi Pens, will be carried and distributed by Camp Staff except Inhalers, which must be carried at all times by children needing them.
  1. All over-the-counter medications must be properly labeled, in original packaging, with written instructions, placed in a Ziploc bag with the camper’s name, and given to the Urban Trailblazer Coordinator upon check-in.
  1. Prescription Medication: If your child is bringing medication prescribed by a physician, please send it in its original packaging with the doctor’s medication order, dosage administration guidelines, and reason for medication clearly noted.

OVER THE COUNTER and PRESCRIPTION MEDICATION

Will your child be bringing over the counteror prescription medication with him/her? ____Yes____No If yes, please complete the following list:

MEDICATION / DOSAGE / REASON

Do you want your child to be responsible for administering his/her own medication? If yes, please sign below. (If no, all prescription medicine must be turned over to Backyard Bound Youth Summit Staff who will be responsible for its administration) ____Yes____No

Signature of Parent/Guardian ______Date ______

EMERGENCY TREATMENT INFORMATION

If a serious emergency arises during the camp week, we will make every effort to contact you immediately. However, it may be necessary for a physician to attend to your child before the Backyard Bound Coordinator is able to contact you. The Crissy Field Center staff is trained and certified in basic first-aid; however, in order to administer the following over-the-counter medications for minor skin irritations, upset stomachs, allergies, etc., we need your authorization. Please initial each medication you authorize the CrissyFieldCenter staff to give your child during the day or overnight camping trips.

____ Antihistimine (ex. Liquid Benadryl) ____Antibiotic Ointment (eg. Neosporin) ____ Snake Bite Kit

____ Calamine or Tech-Nu (for Poison Oak) ____Anti-Diarrheal (ex. Immodium AD) ____Aspirin/Ibuprofen

Signature of Parent/Guardian ______Date ______

MEDICAL BACKGROUND

Check either YES or NO. If YES is checked, give approximate dates, method of treatment, and/or restrictions.

Explain

Physical Conditions, such as:

Diabetes_____Yes_____No ______

Asthma_____Yes_____No ______

Heart Trouble_____Yes_____No ______

Other (describe)______Yes_____No ______

Emotional/Behavioral Problems*_____Yes_____No ______

Learning Disabilities*_____Yes_____No ______

Other*_____Yes_____No ______

Does your child have any allergic reactions to: (please note reaction)

Bee Stings_____Yes_____No ______

Medications_____Yes_____No ______

Food or Drink_____Yes_____No ______

Other_____Yes_____No ______

Has your child been exposed to any contagious diseases 6 weeks prior to visiting camp?

_____Yes_____No ______

Is child under special treatment?_____Yes ____ No ______

Has child had a tetanus booster?_____Yes_____No Date______

Are immunizations up-to-date?_____Yes_____No ______

.

*To insure that your child has a safe and positive camp experience, please list any special needs that your child may have, including emotional, behavioral or learning disabilities:

______

______

______

______

If your child is under the care of a Social Worker, Psychologist, Behavior Therapist, etc., please fill in:

Doctor/Specialist’s name ______Phone No ______